Persistent High Out-of-Pocket Health Expenditures in Four African Countries - Insights from Malawi, Nigeria, Tanzania, and Uganda

Abstract: Out-of-pocket health expenditures remain high in sub-Saharan Africa and may not conform to the sporadic random effect pattern of illness that shapes cost-sharing provisions intended to prevent excessive health spending. High out-of-pocket (OOP) health expenditures over extended periods remain a largely unexplored issue, often inadequately captured by conventional financial protection metrics typically evaluated at a single time point.

We present different methodologies that assess long-term persistent catastrophic health payments. They incorporate extended timeframes into the analysis, considering both the average changes in expenditure over time and the recurrence of high out-of-pocket (OOP) expenditure incidents. Additionally, we employ empirical strategies to identify the underlying factors contributing to these persistently high OOP health expenditures. We use panel data from four sub-Saharan countries: the Malawi Integrated Household Survey for the years 2002, 2013, and 2016; the Nigerian General Household Survey Panel for years 2010, 2012, 2015, and 2018; the Tanzania National Panel Survey for years 2008, 2010, 2012 and 2014; and the Uganda National Panel Survey for years 2005, 2009, 2010, 2013 and 2015.

Our aim is to evaluate long-term and persistent health payments that illustrate the enduring nature of health expenditures within families. Through the application of various thresholds, we can categorize households into different groups: (i) those with persistent catastrophic OOP expenditures situations (ranging from 12% to 15%); those encountering transient catastrophic conditions (ranging from 30% to 40%), and (iii) households facing recurrent catastrophic health expenditure outcomes (less than 10% in all panels). Our panel regression analysis consistently highlights the susceptibility of certain groups, notably those residing in rural areas, individuals with lower levels of education, the elderly, and those who have undergone hospitalizations. These groups consistently face persistent and high out-of-pocket health expenditures, as revealed across most empirical strategies of our study.

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